**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a plan of care was followed related to a resident's transfer status to where a resident (Resident M) was transferred with one person, without the utilization of a gait belt, and later identified with a subluxation to the right shoulder for 1 of 3 residents reviewed for accidents. The deficient practice was corrected by 6/2/23, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments, education related to transfers and gait belt utilization, and audits related to transfers. Findings include: An incident reported to the Indiana Department of Health (IDOH) survey report system, dated 5/30/23, indicated Resident M was assessed by nursing and observed to have had a possible dislocation to the right shoulder. The type of injury noted was a right shoulder subluxation of the humeral head from the glenoid. The follow up to the investigation indicated that the transfer technique for Resident M should be reevaluated by therapy. The clinical record for Resident M was reviewed on 7/6/23 at 3:10 p.m. The diagnoses included, but were not limited to, epilepsy, anxiety disorder, severe intellectual disabilities, and cerebrovascular disease. A Quarterly Minimum Data Set (MDS) assessment, dated 12/29/22, indicated Resident M needed total assistance with 2 staff persons for transfers and bed mobility. A Quarterly MDS assessment, dated 3/31/23, indicated Resident M needed total assistance with 2 staff persons for transfers and bed mobility. An activities of daily living (ADL) care plan, initiated on 12/29/21 and revised on 3/10/22, indicated Resident M utilized a Broda chair for locomotion, dependent on 2 staff for bed mobility, and dependent on 2 staff for transfers utilizing a Hoyer lift that was revised on 6/8/23. A written statement for CNA 12, dated 5/31/23, indicated she transferred Resident M by holding onto the back of her pants and placed her arm underneath Resident M's arm, by herself. An interview conducted with Unit Manager (UM) 2, on 7/6/23 at 3:00 p.m., indicated she did a walkthrough of the unit where Resident M resides before she left for the day, on 5/29/23, and noted that Resident M was okay without concerns. She returned to work on 5/30/23 and noticed there was an x-ray obtained for Resident M that showed a partial dislocation to the right shoulder. Unit Manager 2 reviewed the nursing schedules to see who was working with Resident M on evening shift. There were 2 Certified Nursing Assistants (CNAs) working and CNA 12 was the one working with Resident M. When CNA 12 was interviewed she indicated, to UM 2, that she transferred Resident M without the utilization of a gait belt and by herself. CNA 12 transferred Resident M by taking one arm holding onto the back of Resident M's pants and the other arm went underneath Resident M's right arm and proceeded to transfer Resident M by herself. Resident M was a two staff assist with transfers prior to being evaluated by therapy and determined to need the utilization of a mechanical (Hoyer) lift. An interview conducted with CNA 4, on 7/7/23 at 11:22 a.m., indicated she had worked at the facility for approximately 10 years. In the past Resident M had been a 2 person assist with a stand and pivot transfer until recently. Resident M now needed the utilization of a Hoyer lift. A progress note, dated 5/29/23 at 9:00 p.m., indicated the following, .the CNA on duty noticed that Res' [Resident M's] R [right] shoulder has a partial dislocation (subluxation) while changing her clothes An x-ray result, dated 5/30/23, indicated an inferior subluxation of the humeral head from the glenoid. An emergency room (ER) note, dated 5/30/23, indicated the following, .XR [x-ray] of the R [right] shoulder obtained and radiologist reads it as subluxed [sic] but not dislocated .will d/c [discharge] back to her facility A policy titled Routine Resident Care, undated, was provided by Corporate Nurse on 7/7/23 at 9:40 a.m. The policy indicated the following, .Procedure .3. Unlicensed staff .a. Provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse .b. Routine care by a nursing assistant includes but is not limited to the following .iii. Assisting with ambulation, transfer, repositioning A policy titled Mechanical Lifts and Transfer, undated, was provided by Corporate Nurse on 7/7/23 at 9:40 a.m. The policy indicated the following, .Procedure .b. Manual lifting can cause injury to both resident and staff and should be avoided A document titled Using a Gait Belt, approval date of 9/10/22, was provided by Corporate Nurse on 7/7/23 at 9:40 a.m. The document indicated the following, .Using a gait belt while transferring or walking a patient will provide you and the patient increased safety and security. You can control a patient's balance and can keep the patient from falling by using a gait belt. You also decrease the chance of hurting your back. Always check the resident's [NAME] to identify the type of transfer device to be used This Federal tag relates to Complaint IN00411601. 3.1-45(a)(2)

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse perpetrated by another resident, resulting in a fall and subsequent hip fracture, requiring a hospitalization, for 1 of 5 residents reviewed for abuse. (Residents S and T) Findings include: The Executive Director (ED) provided a copy of a state reportable incident report on, 2-10-23 at 10:45 a.m., dated 2-7-23, which indicated on 2-7-23 at 3:01 p.m., Resident T entered the room of Resident S while holding a folding chair and attempted to hit [name of Resident S]. [Name of Resident S] grabbed the chair and was pulled out of his seat, resulting in a fall .Staff immediately intervened and [name of Resident T] was placed on 1:1 [one to one] supervision .New order for x-ray for [name of Resident S]. It indicated the ED, Director of Nursing, Medical Doctor, local police department and family were notified and Resident T was sent out to an area geriatric-psychiatric facility for further evaluation and treatment, with Social Services to follow-up with both residents for a minimum of 72 hours and care plans to be revised as needed. In an interview with the ED on 2-10-23 at 9:15 a.m., he indicated both residents resided on the secured advanced dementia unit. He indicated Resident T struck Resident S with a folding chair. From the interviews, it doesn't sound like they were fighting, just near one another and he had picked the chair up and bumped him and [name of Resident S] fell backwards and ended up breaking his hip. The ED indicated Resident S was still hospitalized and expected to return to the facility soon. The ED indicated Resident T was sent out to a geriatric psychiatric facility the same evening and may not be returning to the facility as his family was considering relocating him to another facility. In an interview with CNA 5 on 2-10-23 at 10:33 a.m., she indicated she was working on the afternoon of 2-7-23 on the secured advanced dementia care unit with both Resident S and T, and was familiar with both residents. She recalled hearing loud voices coming from Resident S's room. When she entered the room, she observed Resident T jabbing a folding chair at Resident S, whom she found lying on the floor, adjacent to his bed with his head near the foot of the bed. She indicated Resident S was grabbing at the chair to keep from getting hit and yelling, 'Help me, stop hitting me', while I tried to get the chair away from Resident T. She recalled she was able to get the chair away from Resident T, while she was yelling to get the attention of the other staff on the unit. She recalled CNA 6 was down the hall in the nurse's station. She indicated CNA 6 arrived to assist her within 1-2 minutes. She indicated once she got the chair away from Resident T, she was able to redirect him out of the room. She indicated while Resident S was lying on the floor, it was obvious to her his leg did not look right and she wondered if it was broken, plus he seemed to be in a great deal of pain. She indicated she sent CNA 6 to get help from the other secured memory care unit. QMA 7, arrived soon after to help and check Resident S out. She indicated QMA 7 was able to get his vital signs and between the three of them, were able to get him back to bed. Around this time, LPN 8, the ED and the Social Worker arrived. She indicated initially, they said they weren't going to send him out, but would let the doctor know and probably get orders for in-house x-rays. Resident S was able to tell them he had been sitting in his room in a dining room chair and said he was just sitting there when the other resident came into his room, picked up the folding chair that was folded up and leaning against the wall and started hitting him with it. CNA 5 recalled not long after that, LPN 8 said she had talked to the telehealth physician and had orders to keep him here and get x-rays. CNA 5 indicated Residents S and T were ambulatory. She described Resident S as a resident who occasionally wandered, but tended to stay in his room. CNA 5 described Resident T as having a history of wandering and can be pretty confused at times. She shared, I heard that not long ago, he had given a CNA a black eye. I don't know that he's ever been rough with other residents, but he definitely has been that way with the employees. In an interview with CNA 9 on 2-13-23 at 10:55 a.m., she indicated she was familiar with Resident S and T as she had worked on the secured dementia care unit for over 5 years. She described Resident S as having some cognition issues, but seems higher functioning than some of the advanced dementia care unit residents, but does have some confusion at times and is easily redirectable if having confusion issues. She indicated he did not wander on the unit as he tended to stay in his room a lot. She could not recall any incidents of aggression with this resident. She recalled Resident T had a history of wandering at least daily or more often and this seemed to increase in the afternoons or evenings. He seemed to be searching for his wife or a way to get out of the unit. She indicated he had recently had Covid-19 and seemed to go downhill and seemed weaker after that. CNA 9 Indicated Resident T would be agitated at times and this seemed to correlated to his confusion and wandering. CNA 9 indicated she was not aware of any incidents of aggression aimed at staff or other residents. Normally, he seemed to be easily redirected. This incident was a shock to me, I was very surprised when I heard about it, because I was not aware [name of Resident T] had ever been physically aggressive to anyone. 1. The clinical record of Resident S was reviewed on 2-10-23 at 11:06 a.m. His diagnoses included, but were not limited to unspecified dementia with anxiety and diabetes. He was sent to an area hospital on 2-7-23 for further evaluation and treatment. He was admitted to that hospital on 2-7-23 for a fractured hip. He remained in the hospital as of the exit date of the survey on 2-13-23. 2. The clinical record of Resident T was reviewed on 2-10-23 at 11:32 a.m. His diagnoses included, but were not limited to, unspecified dementia with severe behavioral disturbances, anxiety and depression. Progress notes, dated 1-6-23, related to aggression towards staff, on that date. Upon notification to the psych services Nurse Practitioner, the resident was started on Depakote 125 milligrams three times daily, specific to the behaviors of aggression towards staff. In an interview with the ED on 2-13-23 at 12:32 p.m., he indicated Resident T had been physically aggressive towards one of the aides and had given her a black eye several weeks prior to the interaction with Resident S. Progress notes, dated 2-7-23 at 1:35 a.m., indicated Resident T was found lying on the floor of his room, between his bed and dresser at approximately 12:50 a.m. An assessment at this time revealed no injuries and no complaints of pain. Telehealth medical coverage was notified of the fall with no orders received. A follow up call was made by the telehealth medical coverage approximately one hour later. Notes indicated Resident T had no decline in mental status, but may be weaker than at baseline. Orders received at this time included to have the nurse practitioner to see the resident later in the day and to obtain lab work and a urinalysis. The urinalysis was obtained and the results indicated it was within normal limits. Resident T was care planned for the following behavior and care-related issues: -residing on a secured dementia unit, related to his diagnosis of dementia with behaviors of exit seeking, aggression, wandering and elopement risk. This care plan was developed on 10-18-22. Interventions to accomplish this included, but were not limited to, evaluate need for secured dementia unit; if needed, obtain order for such from physician, with appropriate diagnosis and include any exhibited behaviors, with consent of resident and/or representative; notify the medical provider and representative of any behavioral changes; offer snacks to redirect and redirect when appropriate with diversionary activities. -impaired cognitive function related to dementia with behaviors on 10-18-22 and updated on 1-26-23. Interventions for this issue included, but were not limited to, Observe/document/report to medical provider any changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. -having a behavior problem related to being combative with care, physical aggression, preferring to attempting to assist other residents with needs, such as locomotion or feeding, exit seeking, looking for his spouse, getting into others' personal space, pounding on table with his fists, swinging his cane and being combative or aggressive with staff. This care plan was developed on 10-18-22 and updated on 1-6-23 and 1-26-23. Interventions for this care plan included, but are not limited to approach and speak in a calm manner, consultation with behavioral health professionals, communicate with resident and/or representatives regarding behaviors and treatment, encourage active support from family and/or representatives, encourage participation activities of choice, monitor behavioral episodes and attempts to determine underlying cause and to intervene as necessary to protect the rights and safety of others. An intervention, dated 1-6-23, indicated a medication adjustment was conducted on 1-6-23. This Federal tag relates to Complaint IN00401246. 3.1-27(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The clinical record for Resident 48 was reviewed on 7/26/2022 at 11 a.m. The medical diagnoses included, but were not limited to, unspecified dementia and muscle weakness. A Quarterly Minimum Data Set Assessment, dated 5/25/2022, indicated that Resident 48 was cognitively impaired and needed assistance of staff for transferring and walking tasks. Resident had a history of falling during this review period. A fall care plan, last revised on 7/22/2022, indicated for Resident 48 to have a color code call light for a reminder to use a call light. An observation on 7/26/2022 at 10:36 a.m., indicated Resident 48 laying in bed with her call light clipped to the bottom sheet and covered with her top sheet, white blanket, and then a fleece blanket. The call light was a standard white button call light. CNA 30 assisted resident to stand with walker with stand by assistance. An interview with CNA 30 on 7/26/2022 at 10:39 a.m. indicated she wasn't familiar with Resident 48 and she wasn't aware of Resident 48 needing a special call light. She indicated the resident takes care of herself during the day. A policy entitled, Fall Prevention and Management, was provided by the Executive Director on 7/22/2022 at 10:27 a.m. The policy indicated, that .a fall investigation should begin ., the intradisciplinary team should review all information for the falls the next Daily Clinical meetings, and .A progress not of the discussion should be placed in the resident's chart .Based on interview, observations, and record review, the facility failed to provide adequate supervision for Resident 44 while in a Broda (tilt-in-space positioning chair) chair resulting in a fall with a major injury of multiple broken ribs, failed to provide a fall intervention of a colored call light for Resident 48 , failed to provide supervision for Resident 118 and 119 during smoking activities, and failed to update an elopement risk assessment for Resident 520 for 5 out of 6 residents reviewed for accidents and hazards. Findings include: 1. The clinical record for Resident 44 was reviewed on 7/19/22 at 12:04 p.m. Resident 44's diagnoses included, but not limited to, dementia with behavioral disturbance, anxiety disorder, and closed fracture of left femur neck with routine healing. An incident report regarding Resident 44 was received on 7/21/22 at 3:21 p.m. from ED (Executive Director). It indicated, on 7/3/22 at 1:01 p.m. During morning rounds, resident was found in dining room lying of left side. The immediate action taken indicated, a pain assessment was completed, the Medical Doctor, Executive Director, Director of Nursing and family was notified, and a new order to send Resident 44 out to the local emergency department for further evaluation and treatment. The type of injury was left eye laceration, fx [sic, fracture] along the posterior aspect of the right 7th-10th ribs and additional fx [sic] of the right 8th and 9th ribs. The preventive measures taken were to complete pain assessment, notify necessary persons, send the resident out to emergency room and upon return to: complete a skin assessment, have social services follow up for 3 days to ensure no psychosocial distress, physical therapy to evaluate, and the care plan to be reviewed and updated as appropriate. The follow up dated, 7/8/22, indicated, Resident 44 returned to the facility with no new orders from the hospital, to continue on hospice services for pain management and comfort care, social services to follow for 72 hours for possible psychosocial distress and noted the care plan had been updated. A nursing note dated 7/2/2022 at 6:10 a.m. indicated, This writer[sic] notified by CNA[sic, Certified Nursing Assistant) that resident was on the floor in dining room and bleeding. This writer [sic] to dining room and noted resident to be on the floor and next to his wheelchair. Laying slightly on his left side, there was a large amount of blood noted underneath resident's head. This writer assessed and noted it to be coming from a laceration next to residents left eye. Pressure put on wound immediately. No other immediate concerns noted at this time. Resident conts [sic, continues] to talk and interact with staff per his usual. 911 called. 911 transported res [sic, resident] to [sic, name of local hospital] ER[sic, emergency room] for eval[sic, evaluation] et[sic, and] tx[sic, treatment], they were made aware he was a hospice pt[sic, hospice]. The emergency room notes were received on 7/25/22 at 2:55 p.m. from MDS (minimum data set coordinator) 62 and dated 7/2/22 at 7:01 a.m It indicated, Resident 44 presented to the emergency room after an unwitnessed fall at the facility. The report given to nursing staff was that the patient was found down in the dining room and felt that the patient tried to get up from his chair then fell. The chest/abdomen/pelvis CT (computed tomography) scan revealed fractures along the posterior aspect of the right 7th through 10th ribs and additional lateral fractures of the right 8th and 9th ribs. An interview with CNA 61 was conducted on 7/26/22 at 11:29 a.m. She indicated, she had just come in for her day shift on 7/2/22. The night shift staff were right by the units locked entry door. She stated, one staff person was about to take the trash out and another staff member was checking on the residents at that end of the hallway. She indicated, she walked down the hall and that's when she saw Resident 44 on the floor in the dining room next to his Broda chair and he was bleeding from his head. She asked him if he was ok and he replied oh, my head. She stated the Broda chair was in the tilted back position when he was found on the floor. She indicated, she hadn't heard any loud noises as she walked down the hall. She stated, she worked on the unit where Resident 44 resides quite often and was very familiar with Resident 44. She indicated, when Resident 44's Broda chair was in the reclined position she observed him sitting up in the chair as well as trying to stand up. Resident 44 also had falls with and/or without injury on the following dates: -4/4/22 at 1:37 p.m. while ambulating -5/11/22 at 4:53 p.m. from bed -5/18/22 at 2:15 p.m. from bed -6/3/22 at 9:50 p.m. from bed An interview with SSD (Social Services Director) 9 was conducted on 7/25/22 at 2:29 p.m. ED (Executive Director) was also present during the interview. SSD indicated, Resident 44 was declining in his health. She further indicated, she received an email from Resident 44's hospice provided which indicated Resident 44 was ordered the Broda chair for comfort and multiple falls. An interview with Resident 44's hospice LPN (licensed practical nurse) was conducted on 7/26/22 at 12:00 p.m. She indicated, she had been seeing for Resident 44 about once a week every week and some weeks twice since he has been on hospice service. She indicated, he was usually in his Broda chair either in an upright or reclined position. She indicated, Resident 44 was attempting to get up out of his Broda chair a lot during this visit and any attempt to get out of any chair would be considered dangerous for him. Neither Resident 44's hospice care plan, nor the facility's care plan addressed the need for increased monitoring and/or supervision for a resident with multiple falls. The facility failed to provide adequate supervision to prevent accidents. 5. The clinical record for Resident 520 was reviewed on 7/20/22 at 11:03 a.m. The Resident's diagnosis included, but was not limited to, Alzheimer's disease. She was admitted to the facility on [DATE]. An admission Initial Evaluation, dated 7/13/22, indicated she was able to ambulate independently, without the use of a wheelchair or an assistive device. She had not displayed pacing with no course of action or direction, attempts to exit door, or wandering without a sense of purpose. A Behavior Note, dated 7/14/2022 at 5:45 p.m., read . Resident has been pacing the floor all day. Resident has tried getting outside multiple times and setting off alarms. Resident has been oriented to safety issues and to let staff know when she wants to go outside. Resident forgets this almost immediately. A SBAR (Situation, Background, Assessment and Recommendation) Communication Form, dated 7/14/22, indicated she was experiencing behavioral changes, described as pacing and intrusively entering other resident's rooms. On 7/20/22 at 1:00 p.m., Resident 520 was observed standing in the hallway by the community outdoor sitting area exit door. A staff member was walking through the courtyard and entered the door. She spoke briefly with Resident 520 and let her out into the sitting area. There were no staff members present in the sitting area. During an interview on 7/21/22 at 9:06 a.m., LPN (Licensed Practical Nurse) 20 indicated that Resident 520 was fairly new to the facility. She was a wanderer. She would wander around the facility and would get lost on the other unit. The staff would bring her back to her room. She was pleasantly confused. She did go outside to sit at times. During an interview on 7/21/22 at 9:00 a.m., Resident 520 indicated she had been at the facility for about 4 weeks. She was unsure of why she was there. She would go home when her family came to get her. During an interview on 7/22/22 at 11:37 a.m., SSD (Social Service Director) 7 indicated Resident 520 should have been reassessed for elopement risk after her change in behavior and that social services had not been made aware of her continued or intrusive wandering. She did not have a care plan for wandering or elopement risk. On 7/21/22 at 3:22 p.m., the Executive Director provided the Elopement Prevention Policy, last reviewed 4/20/17, which read . 1. Identify resident/[sic] patient who are at risk for elopement. a. All new admissions that are at risk for elopement will have interventions put into place immediately until further assessment is complete .b. Any resident/[sic] patient admitted who is cognitively impaired and can self-ambulate is considered an elopement risk until determined otherwise. c. Any resident/[sic] patient that has a change in condition that places them at risk for elopement . 3.1-45(a)(2) 3. The clinical record for Resident 118 was reviewed on 7/19/22 at 3:00 p.m. The diagnosis for Resident 118 included, but was not limited to, dementia. The resident was admitted on [DATE]. An admission MDS (Minimum Data Set) assessment, dated 7/8/22, indicated Resident 118 was cognitively impaired. A smoking assessment dated [DATE] indicated Resident 118 needed supervision for smoking safety. 4. The clinical record for Resident 119 was reviewed on 7/19/22 at 3:15 p.m. The diagnosis for Resident 119 included, but was not limited to, chronic obstructive pulmonary disease. The resident was admitted on [DATE]. An Admissions MDS (Minimum Data Set) assessment, dated 7/8/22, indicated Resident 119 was moderately cognitive impaired. A smoking assessment dated [DATE] indicated Resident 118 needed supervision for smoking safety. An observation was made of Resident 118 and Resident 119's room on 7/19/22 at 3:00 p.m. Resident 118's bed was observed with a red lighter lying on the bed. Resident 119 indicated at that time, that her and her roommate (Resident 118) hold their own tobacco products and go outside and smoke. She indicated she was going back outside to smoke. Resident 118 was currently outside smoking. An observation was made of Resident 118 and Resident 119 in the courtyard on 7/19/22 at 3:11 p.m. The residents were observed outside sitting in chairs inside a two sided wall up against a door smoking. There were no staff present in the courtyard supervising the smoking activity. An interview was conducted with the Nurse Consultant on 7/19/22 at 3:19 p.m. She indicated Residents' 118 and 119 needed to be reassessed for smoking. The smoking assessments were conducted on admission. A smoking procedure and policy was provided by the Executive Director on 7/21/22 at 10:01 a.m. It indicated .Definition: .Supervised Smoker: A resident is unable to demonstrate safe smoking habits including smoking materials management, lighting, controlling cigarette ash and extinguishing smoking materials and requires staff supervision when smoking. Policy: It is the policy of this facility to promote resident centered care by providing a safe smoking area for residents/patients that request to smoke and are capable of safe smoking behaviors either independently or with supervision unless facility is a designated non-smoking facility .8. Facility staff will: a. Secure smoking materials in a locked area when not in use by the resident/patient for supervised smokers .